The criminal justice population is large, growing, and has a high prevalence of substance use disorders. Prior research by Dr. Binswanger (PI) has demonstrated that former inmates were at high risk for death, especially in the first two weeks after release from prison. Nearly one quarter of all deaths was due to drug overdose; many other causes of death were related to substance abuse. Individuals with HIV are at risk for overdose- related mortality, particularly drug-dependent individuals with HIV. Furthermore, drug overdose mortality has been increasing in the United States, especially from opioid analgesic use. However, little is known about drug- related risk factors for death after release from prison. The proposed study will examine the drug-related risk and protective factors associated with death after release from prison over a ten year period, with an emphasis on substance dependence, narcotic prescriptions shortly before release, HIV status, and in-prison substance dependence treatment. The objectives of this study are to examine the following aims in former inmates: 1) determine the drug-related risk factors for all-cause and overdose mortality after release from prison, including substance dependence, as identified in prison, narcotic prescriptions provided shortly before release, and known HIV infection; 2) determine if substance dependence treatment delivered in prison reduces the risk of death after release from prison; and 3) determine the risk of death from all causes and drug overdose after release from 1999-2008. These aims will be achieved using a retrospective longitudinal cohort design with data from approximately 50,000 male and female inmates released from the Washington State Department of Corrections, followed by a nested case control study of approximately 1600 former inmates with clinical chart abstraction. Understanding the epidemiology of substance dependence, substance dependence treatment, and drug- related mortality after release from prison will guide further research in a broader range of criminal justice populations including prisoners in other states, federal custody and jail. These results will also inform further research into substance dependence screening and treatment in correctional facilities and the development of a targeted intervention to reduce the risk of drug-related deaths after release from prison. PUBLIC HEALTH RELEVANCE: The criminal justice population is large, growing, and has a high prevalence of substance use disorders and HIV. Former inmates are at high risk for death after release from prison, particularly from drug-related causes. This proposal will determine if substance dependence, prescribed narcotic use prior to release, and HIV are associated with an elevated risk of death after release from prison, and if substance dependence treatment in prison is protective. These findings will be used to develop interventions aimed at reducing the risk of death during the transition from prison to the community.